Vol.2, No.7, 759-768 (2010)
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
Costing of Malaria treatment in a rural district hospital
Insa Koné, Paul Marschall*, Steffen Flessa
University of Greifswald, Faculty of Health Care Management, Greifswald, Germany;
*Corresponding Aut hor: Paul.Marschall@uni-greifswald.de
Received 7 January 2010; revised 18 February 2010; accepted 20 February 2010.
Objective: It is the aim of this paper to estimate
the provider’s cost of treating paediatric cases
of Malaria in a rural African hospital. Further-
more, we intend to give some insights into the
possibilities of improving the efficiency of treat-
ing children with this disease in order to sup-
port policy makers in the resource allocation
process. Methods: The cost analysis was done
in the district hospital of Nouna, Burkina Faso.
Based on a comprehensive cost-of-illness in-
formation system, the cost of treating paediatric
Malaria in the district hospital in the year 2005
were estimated using a combination of top-
down and activity-based costing. It divides the
entire treatment process into a set of activities
along the clinical pathway and allocates mone-
tary values for the resource consumption to
each activity. Results: The average actual pro-
vider’s cost were 6.74 US$ for a paediatric out-
patient with Malaria, 61.08 US$ for a paediatric
Malaria inpatient with anaemia and, respectively
74.29 US$ for a case of paediatric Malaria with
neurological affection. 54% of the cost was due
to laboratory work. This high unit cost was
mainly due to a severe underutilisation of the
hospital capacity. The current cos t re covery rate
per case was between 18% and 43%. It would be
between 32% and 73% if the occupancy in-
creased to 80%. Conclusion: The paper demon-
strates that detailed costing is possible in a
district hospital in rural Africa. The unit cost
seems to be extra-ordinary high and the share
of laboratory cost is tremendous. However, this
is mainly due to a very strong underutilisation
of the existing capacities. This fact calls for in-
tensive efforts of the management of the insti-
tution to attract more patients by improving the
quality of services and in particular the satis-
faction of the patients.
Keywords: Burkina Faso; Cost Analysis;
Clinical Path way; Cost Recovery; Paediatric Malaria
Malaria is one of the most common diseases and a major
obstacle for economic and human development in
sub-Saharan Africa (SSA) [1,2]. In particular children in
this region suffer from high morbidity and mortality
caused by Malaria [3]. For instance, in Burkina Faso in
the year 2005 54.94% of the hospitalisations of children
under the age of five were due to Malaria and the disease
was with 57.29% the leading cause of death of un-
der-five-years-olds [4]. In the health district of Nouna in
the North-West of Burkina Faso Hammer et al. [5] ana-
lysed the causes of mortality for children and found that
Malaria was the most frequent diagnosis (42%) in this
district for the years analysed (1999 to 2003).
Although the magnitude of human suffering due to
Malaria is well known and a wide range of research
about Malaria prevention and effective treatment is on-
going, there is very little knowledge about the cost of
treating Malaria in hospitals. Compared with the magni-
tude of studies on the epidemiology of Malaria in SSA,
the number of studies focusing on the cost of this disease
in hospitals is extremely low. Provider’s cost per paedi-
atric inpatient were estimated at 86 US$ (user fees 43
US$) in a tertiary hospital in Senegal for the year
1996/97 [6] and at 57 to 105 US$ in a district hospital
and 33 to 44 US$ a sub-district ho spital in Kenya for the
year 1993/94 [7]. Recently, Ayieko et al. [8] estimated
provider’s cost of treating paediatric Malaria in district
hospitals in Kenya between 47 and 75 US$ for the year
2005 without distinction b etween mild and severe cases.
In the Ivory Coast total user fees for a hospitalised pae-
diatric Malaria inpatient were estimated and resulted in
15 to 40 US$ per child [9].
The majority of studies build on a snap-shot cost
analysis in the hospitals an d not a routine costing system.
There is an urgent need to determine the cost-of-illness
of Malaria and in particular of the cost of Malaria pa-
I. Koné et al. / HEALTH 2 (2010) 759-768
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
tients in hospitals in this region based on a professional
routine cost-of-illn ess information system.
This paper intends to contribute to the process of fill-
ing this gap. The motivatio n for this research is based on
the conviction that proper resource allocation and an
efficient roll-back of Malaria will only be possible if we
know the cost of this disease so that managers can make
informed decisions. The scope of the paper is limited to
paediatric Malaria in Nouna district hospital, Burkina
Faso. This example was chosen because a comprehen-
sive cost-of-illness information system was established
in this district in 2003 and Malaria has been an interna-
tional research subject in this region for many years. The
cost-information system covers direct and indirect cost
as well as cost of first-line facilities and the district hos-
pital. The methodology of the information system and
the basic costing results were described elsewhere [10,
11]. The restraint to paediatric cases seems appropriate
as the majority of grown-up Malaria patients already
have semi-immunity and are generally treated as outpa-
tients in rural health centres.
For this paper we used the existing cost information
system and extracted the cost of treating paediatric Ma-
laria patients in the district hospital to calculate pro-
vider ’s cost per patient. Consequently, the second section
of this paper describes the costing methodology based on
the actual patient’s pathway in Nouna district hospital.
Section three presents the results and section four dis-
cusses the consequences of these results for the hospital
management. The paper closes with a few conclusions.
The methodology applied for calculating the treatment
cost of paediatric Malaria patients in the d istrict hospital
of Nouna is a combination of top-down and activity-
based costing.
The top-down costing methodology was first devel-
oped for commercial commodities where up to 90% of
cost is variable (e.g. cost of materials) and the rest
(overheads) can be allocated proportionally to the cost-
ing units. This costing methodology has also been ap-
plied to hospitals [12-14]. A common approach is to di-
vide the total cost of the institution by the number of
patient days in order to determine the cost per patient
day. The co st per patient is computed by multiplying the
length of stay by the average cost per patient day.
However, up to 80% of total cost of hospitals is fixed
and does not vary with the number of patient days.
Therefore, allocating fixed cost to the diseases and pa-
tients according to the length of stay induces a severe
error. In particular, the top-down approach does not al-
low any judgement on the impact of increased or de-
creased work load of an institution as fixed cost are
proportionalised. Also, the methodology does not allow
to distinguish patients with different diagnosis at the
same ward and often gives only a rough picture of the
real cost of a patient with a specific diagnosis.
Therefore, advanced costing methodologies have been
established for the service industry and in particular for
hospitals. They divide the entire treatment process into
several activities or sub-processes and calculate the total
cost of a particular patient or diagnosis by adding up the
cost along the clinical pathway [15]. This activity-based
(or bottom-up) costing has become a standard in the de-
veloped world [16-18], but it is hardly applied in hospi-
tals of developing countries as it is quite detailed and
requires a degree of precision of documentation and re-
cording that is frequently not existing in these countries
In a nut-shell, the top- down costing approach is faster
than but not as precise as the activity-based costing. On
the other hand activity-based costing requires very de-
tailed cost information which is hardly available in de-
veloped countries and ev en less in developing countries.
Consequently, a combination of top-down and bot-
tom-up costing was chosen to calculate costs at a paedi-
atric ward for the specific diagnosis Malaria with the
available cost data. This mixed approach has been ap-
plied to similar problems before, e.g. [21].
The first step was the analysis of the existing costing
data. The provider cost information system has been
established in the hospital since 2003. As for standard
step-down cost analysis cost centres were defined, with
the difference, that any department directly in contact
with the patient (e.g. ambulance, laboratory) was defined
as final cost centre. The only overhead cost centres were
laundry service and technical service. Cost for overhead
cost centres were allocated to the other cost centres (e.g.
administration, wards, laboratory etc.) according to the
worklo ad and added to th e cost per serv ice unit of a par-
ticular cost centre (e.g. cost per laboratory test). Inter-
mediate cost centres were not defined as all other cost
centres provided services which could be directly linked
to the patient. Within each of the final cost centres a va-
riety of products were defined, e.g. at the laboratory 44
different tests. Cost for each of them were calculated by
the ingredient’s approach, where the final price is the
product of the quantity o f inputs used and their value per
unit [22,23]. This means that wherever possible cost
were directly allocated to a specific laboratory test (staff
costs per minute, equipment, consumption material) only
overhead cost (electricity, building etc.) were divided by
the total number of laboratory tests as in a top-down
The second step was the design of a standard pathway
I. Koné et al. / HEALTH 2 (2010) 759-768
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of paediatric Malaria cases in the hospital. For this pur-
pose, we analysed 40 files of respective in- and outpa-
tients of the year 2006 with Malaria as diagnosis. In ad-
dition, we interviewed the personnel in charge (physi-
cian, nursing o fficer, head of laboratory, drug sell er, head
of technical service, chauffeur, head of laundry) to tri-
angulate the findings [24,25]. Finally, direct observation
provided information of workload and material con-
sumption of procedures (ward round, laboratory tests
etc.). The fact that we chose patient files from 2006 was
due to a lack of reliable files for 2005. However medical
staff reassured us that there had not been major changes
in treatment during this period. Based on our findings a
standard pathway was developed in accordance with the
guidelines for Malaria treatment for Burkina Faso [4]
and of the World Health Organisation [26]. The com-
parison with these guidelines seemed appropriate as we
suspected under-provision due to patients’ financial
straits. Possibly, treatment is sometimes abandoned be-
fore its time as the patient runs out of money. It was
however our intention to estimate cost for a complete
The third step was to calculate the total cost per pa-
tient by summing up the cost along the clinical path-
In addition, total user fees were calculated. As patients
have to pay fees for particular services, the total fees
were calculated by adding up all user fees along the
standard pathway.
The cost of treatment in rural health centres, the cost
of pharmacies, private transportation and indirect cost
(such as cost of food, accompanying family members,
lost labour time etc.) were not considered. Drug cost
within the hospital were only considered when directly
associated with Malaria and its complications, e.g.
anaemia. Antibiotics, v itamins and others were left aside.
Within the cost centres variable and fixed cost were
distinguished (Table 1) and the cost behaviour of all cost
categories was analysed. Variable cost rise proportion-
ally with service units (e.g. any further patient) while
fixed cost do not change [14,27]. Drugs, for instance, are
consumed proportionally to the number of patients and
can be allocated directly to a particular patient or diag-
nosis. On the other hand, the cost for equipment are
fixed and will not increase if more patients are hospital-
ised. Consequently, the average fixed cost per patient
will decrease with a growing occupancy as the cost are
distributed among more patients (fixed cost degression).
Electricity was judged to be in parts fixed and in parts
variable. On one hand, for example, the lightning needed
for a 6-bed-bedroom does not depend on the number of
patients occupying it (it remains the same, whether oc-
cupied by one person or by six persons). On the other
Table 1. Cost behaviour of different cost categories.
Fixed cost Variable cost
Building depreciation 100%
Consumables 100%
Electricity 50% 50%
Equipment/vehicles depreciation 100%
Fuel 100%
Pharmaceuticals 100%
Salaries and wages 100%
Technical services 100%
hand, usage of medical devices accounts for a propor-
tional rise in electricity with any further usage.
Tabl e 2 gives an overview of total cost in cost centres
related to paediatric Malaria for the year 2005 [28].
Based on this data from the cost information system
we estimated unit cost for the services along the standard
pathway including ambulance transport from a rural
health centre to the hospital, laboratory tests, a bed day
at the paediatric ward, medical and nursing care per day,
drugs and the administrative procedure per patient from
the provider’s point of view as described above.
Figure 1 demonstrates the standard pathway of a pae-
diatric Malaria patient in Nouna hospital. Although, the
clinical perception of every patient is different, the series
of sub-processes in the inpatient department is quite
similar for almost all patients. The patient enters the
paediatric ward, either because he is referred to the hos-
pital by a rural health centre or because the relatives
(usually parents) themselves decide to bring the child
directly to the hospital. If necessary the hospitals ambu-
lance is sent to fetch the child at the rural health centre.
The first resources within the hospital are consumed by
the consultation at the paediatric ward including anam-
nesis and physical examination. At the same time, regis-
tration involves the consumption of administrative time.
Depending on the general state and the Malaria symp-
toms the child is either admitted or treated as an outpa-
tient. The stan dard treatment of an outpatien t with mil der
Malaria is either Sulfadoxine/Pyrimethamine or Amo-
diaquine and an antipyretic agent in oral form. A thick
blood film/blood smear is done at the laboratory to af-
firm the suspected diagnosis.
If the child is hospitalised an inpatient file is opened
by the nurse or the physician and medical and nursing ,
I. Koné et al. / HEALTH 2 (2010) 759-768
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Figure 1. Standard pathway of paediatric Malaria patients at Nouna district hospital.
Openly accessible at
I. Koné et al. / HEALTH 2 (2010) 759-768
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Table 2. Total cost of cost centres involved of paediatric Malaria treatment [US$] in Nouna hospital in the year 2005.
Department Building
depreciation Equipment/vehicles
depreciation Salaries &
wages Consumables Technical
services Fuel PharmaceuticalsTotal
Administration 449 0 6.404 1.121 19.720 4.358 0 32.050
Electricity 41 0 0 0 19.582 0 0 19.623
Laboratory 2.166 22.950 10.582 4.245 0 0 0 39.943
Laundry 0 0 450 0 0 0 0 450
Paediatrics 971 473 12.910 0 0 0 0 14.354
Pharmacy 196 6 2.239 83 0 0 50.655 53.179
services 62 136 3.370 0 2.489 0 0 6.057
Transport 0 0 0 0 0 0 0 0
Total 3.885 23.565 35.955 5.449 41.791 4.358 50.655 165.658
care starts. Directly connected with the examination is
the preparation of blood-samples for the laboratory.
Laboratory tests are asked according to clinical findings,
e.g. paleness leads to a haemoglobin count/haematocrit.
At the same time, parents or other accompanying rela-
tives are instructed to buy drugs from the hospital phar-
macy according to the clinical symptoms. Hospitalised
Malaria cases receive intravenous anti-Malaria treatment
with Quinine. The main symptoms of severe Malaria at
the district hospital are anaemia (Hb < 6 g/dl) and con-
vulsions. Clinic diagnosis of anaemia is confirmed by a
haemoglobin count/haematocrit going along with a
blood grouping. Blood transfusions are done accordingly,
if the haemoglobin level is below 6 g/dl. Donors are
mostly family members, thus cost occur only for blood
collection, infectious screening and blood grouping. As
long term treatment the children receive oral iron as sub-
stitute. Convulsions are treated with Diazepam. As Ma-
laria symptoms are non-specific and might also be due to
other infectious diseases, e.g. a gastro-enteritis or intes-
tinal parasites, further laboratory tests can be required,
e.g. blood count or wh ite blood cell count or/and lumbar
puncture. The examination of the patient’s general state
is repeated daily in form of the ward round and if neces-
sary further laboratory tests are asked or/and drugs pre-
scribed accordingly. The discharge depends on the gen-
eral state of the patient. To give two important features,
the child should by then be able to swallow and take an
oral anti-Malaria agent and the body temperature should
have dropped below 37.5°C. In the year 2006, the aver-
age length of stay of a paediatric inpatient with severe
Malaria was 3.5 days (standard deviation 1.4) for cases
with anaemia and 7.25 days (standard deviation 2.2) for
cases with neurological affection. An average first con-
sultation took 15 minutes.
Along the standard pathways costs were summed up
assuming either an case of mild Malaria treated as an
outpatient (Tab le 3) or the case of severe Malaria with
either anaemia or neurological affection (Ta ble 4). Cost
resulted in 6.74 US$ for a paediatric outpatient with mild
Malaria and 61.08 US$ for severe Malaria with anaemia
and 74.29 US$ for Malaria with neurological affection.
The extra-ordinary high cost of the laboratory (54%
on average) call for more analysis. A closer look reveals
that the depreciation of equipment accounts for 64% of
the total cost and that almost 88% of the laboratory cost
are fixed cost (Figure 2). Considering the manpower it
can be estimated that the number of tests performed
could be increased by a factor of at least four without
bringing the laboratory staff to their capacity limit. The
combination of high fixed cost and low utilisation rate
explains why the actual cost are quite high.
User fees are shown in Figure 4. An outpatient pays
Building depreciation (7 .6%)
Consumption Material (9.3%)
Electricity (6.3%)
Equipme nt depreciation (64.0%)
Technical services (0.6%)
Salaries & wages (12.0%)
Figure 2. Distribution of laboratory cost in Nouna hospital in
he year 2005. t
I. Koné et al. / HEALTH 2 (2010) 759-768
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Table 3. Cost for standard outpatient paediatric Malaria case in Nouna hospital in the year 2005.
Unit cost (US$) Quantity per patient Cost per patient (US$)
Staff 0.60 1 0.60
Overhead cost 1.34 1 1.34
Laboratory 3.36
Thick blood film/Blood smear 3.36 1 3.36
Administration 0.76 1 0.76
Table 4. Cost for standard paediatric inpatient case with severe Malaria in Nouna hospital in the year 2005.
Anaemia Neurological affection
Unit cost (US$) Quantity per patientCost per patient (US$)Quantity per patient Cost per patient (US$)
Ambulance 7.49 0.00 0.00 1.00 7.49
Paediatric ward 13.83 28.64
Medical care/day 0.48 3.5 1.68 7.25 3.48
Nursing care/day 1.19 3.5 4.17 7.25 8.63
Bed/day 2.28 3.5 7.98 7.25 16.53
Laboratory 41.14 31.97
Thick blood film/Blood smear 3.36 2 6.72 2 6.72
Haemoglobine count/Haem atocrit 8.00 1 8.00 0 0.00
Blood grouping 4.26 1 4.26 0 0.00
Blood count 4.90 1 4.90 1 4.90
Stool smear 2.94 1 2.94 1 0.00
Blood transfusion 14.32 1 14.32 0 0.00
Cerebrospinal fluid 18.63 0 0.00 1 20.35
Pharmacy 5.36 5.43
Administration 0.76 0.76
Total 61.08 74.29
2.88 US$ and inpatients pay 16.29 US$ in case of severe
Malaria with anaemia and 13.37 US$ in case of neuro-
logical affection. This results in a cost-recovery rate of
43% for an outpatient and 27% and 18% for the inpa-
tients. The low cost-recovery for Malaria with neuro-
logical affection is due to the fact that the examination of
cerebrospinal fluid (CSF) is done within the scope of a
research project about meningitis and therefore free of
charge for the patie n t.
This paper investigates to calculate the cost of treating
paediatric Malaria based on a standard pathway and ac-
tivity-based costing as an example for an appropriate
method to estimate the COI in a resource-poor setting.
I. Koné et al. / HEALTH 2 (2010) 759-768
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Cost per case in Nouna district hospital are comparable
to what was found in similar settings in Senegal and
Kenya [6-8]. However, this should not mislead the
management to assume that the situation in Nouna hos-
pital is sound. Instead, there seems to be substantial
wastage of resources, namely expensive devices and
labour time of staff due to underutilisation.
High expenditures at the laboratory in Nouna are par-
ticularly due to high fixed cost particularly for equip-
ment. The hospital is, in general, in a rather poor condi-
tion. However, the laboratory’s building is brand new
and holds up-to-date equipment not yet written off. Con-
sequently, this department has comparably high cost. In
addition, the department is strongly underutilised.
What was shown ex emplarily for the laboratory is also
valuable for other cost centres. If the hospital utilisation
rate increased from currently 20% to 80% (NB: an oc-
cupancy between 80 and 85% is internation ally seen as a
professional standards [18]), the cost per inpatient would
decrease to 34.59 US$ (paediatric Malaria with aenae-
mia) and 42.35 US$ (paediatric Malaria with neurologi-
cal affection), whereas the cost for an outpatient visit
would decrease to 3.95 US$. Cost per bed day at the
paediatric ward (including building, equipment and
overhead cost) would decline by 64% and laboratory
cost would decline by 54% per patient. Figure 3 shows
the cost for the standard treatment per patient against the
occupancy rate.
Assuming that user fees per patient would not change
in case of higher occupancy rates, cost-recovery would
increase to 73% for outpatients and 47% (paediatric
Malaria with anaemia) resp. 32% (paediatric Malaria
with neurological affection) for inpatients.
The costing method applied might furthermore mask
higher fixed cost for medical and nursing staff. As we
allocated staff cost according to the time spent for a cer-
tain patient, we do not account the additional free
time caused by the lack of patients. If we divided total
Figure 3. Cost for standard treatment against occupancy rate in
Nouna hospital in the year 2005.
Figure 4. Provider’s cost and user fees in Nouna hospital in the
year 2005.
staff cost at the paediatric ward or at the laboratory by
the number of patients or tests, cost per unit would be
even higher.
The low occupancy rates and general underutilisation
of health care in Nouna health district [29-31] and
Burkina Faso as a whole [32] lead to high average cost
per patient especially for staff [11,33]. To improve effi-
ciency utilisation shou ld be enhanced.
Possible reasons for low utilisation might be existing
patients’ dissatisfaction with the quality of health ser-
vices [30,34-36] leading to a preference towards tradi-
tional healers or self-treatment. Baltussen et al. [37]
found that the quality of care perceived at Nouna hospi-
tal was even worse than th at of rural health centres.
Further reasons for low utilisation rates might be the
distance to the health care facilities, as well as the influ-
ence of financial barriers [31,38]. Although longer dis-
tances to rural health centres can be avoided even in ru-
ral areas by appropriate planning [39] there does not
seem to be an easy solution for the distance to the hospi-
User fees, on the other hand, were introduced accord-
ing to the Bamako Initiative to make health care sus-
tainable. Furthermore the correlation between better
quality and increasing utilisation rates was shown by
Litvack and Bodart [40] and Mariko [41] and was
stronger than between abolition of user fees and utilisa-
tions rates. Thus management efforts have to focus on
the quality of h ealth care services in Nouna as elsewh ere
in SSA.
Our findings underline the results of other authors that
a standard pathway is a useful tool not only for costing,
but also to ameliorate the quality of care in cooperation
with the health personnel [24,42] by establishing a stan-
dardised sequence of interventions along the patient’s
hospital stay. Criteria should be defined under which in-
vestigations are required within predefined time-frames.
Any performed investigation has a consequence for the
ongoing treatment and if at a certain point the treatment
does not show the expected effects alternatives are fore-
I. Koné et al. / HEALTH 2 (2010) 759-768
Copyright © 2010 SciRes. Openly accessible at http://www.scirp.org/journal/HEALTH/
1), 47.
seen. Furthermore, prefabricated patient files based on
the clinical pathway could be developed, wh ich simplify
documentation. Also, total cost can be estimated already
at the moment of admission and provide planning reli-
ability to the health care provider as well as to the pa-
tient or his accompanying relatives. In Guinea-Bissau,
for instance, it was shown, that a standardised protocol
for the management of paediatric Malaria can lead to a
decrease in mortality and average hospital stay, when
going along with monitoring and a financial incentive
for the staff [43].
Activity-based costing is an appropriate method to cal-
culate the COI even in resource-poor settings and thus
can be an important starting point to investigate ineffi-
Higher occupancy rates are the crucial point for a
more proper resource allocation and a more efficient
Malaria treatment in Nouna district hospital. Further
development of the clinical pathway might be a positive
incentive to improve quality of care and thereby render
the hospital more attractive for the population to accen-
tuate demand for modern healthcare. Increasing the
utilisation of the district hospital would also help to
make the hospital more sustainable as cost-recovery
rates would considerably augment. Nevertheless, it is
hardly possible that the hospital in its current configura-
tion will break even.
A major share of total provider’s cost is due to fixed
cost. Increasing utilisation helps to lower average cost
per case, ceteris paribus. Furthermore, unnecessary cost
should also be avoided. For example before investing in
new equipment for example at the laboratory, it should
be verified if further devices are adequate for a district
hospital in a developing country.
We are aware that the suggested oral Malaria treatment
changed lately to ACT (Artemisinin-based combination
therapy) to control the growing resistance against anti-
Malaria agents [26]. This treatment option was not avail-
able at Nouna district hospital in the years 2005 and
2006. The introduction of ACT might slightly increase
provider cost for drugs, but does probably not change
total treatment costs substan tially as drug cost stand only
for a small part of total provider’s cost.
It was not possible to evaluate the level of patients’
unofficial payments. It is likely they do pay for better or
faster treatment, especially since considerable “hidden
cost” were discovered in other low-income countri es [44].
On the other hand, exemption mechanisms for indi-
gents and pupils were also not considered when calcu-
lating total user fees and co st-recovery rate.
We would like to thank the German Research Society (DFG) for fund-
ing this study as project of SFB 544. We would also like to express our
gratitude towards Ali Sié, Germain Savadogo, Dimitri Poda and Atha-
nase Pacéré for supporting data collection for the cost information data
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